Targeted geted Case e Manage agemen ent (TCM) M) Pr Proposed posed Med edicai caid d St State e Pl Plan n Am Amen endmen dment
12/23/11 – Publication of proposed TCM draft SPA to SCDHHS website. 12/31/11 – 01/31/12 Comments accepted on TCM draft SPA. 01/24/12 – Public meeting held at SCDHHS on proposed TCM SPA. 01/31/12 – Comments period ended. Received
Februa uary y 20 2012 12 Review of Comments Visit Sample of Providers March ch 20 2012 12 Review Coverage Sections Review Rates
Subjec ect/ t/Theme Theme Source rce Parent (26) Budget Cut (32) DDSN Board (11) Rate methodology (36) Private Provider (5) Frequency (9) Consumer (2) Quality of Care (1) Unknown (2) Freedom of Choice (3) Advocacy (2) Direct enrollment (2) Other Family (2) Alternative Cost Saving (1) Attendance (4) Not applicable (4) Stressful (5) CM Assistant (3)
Nine target populations Proposed effective date of 01/01/2013 Medical necessity (Required of all Medicaid Services) Prior authorization by QIO Utilization control All providers begin utilizing 15 minute unit of service
Provider agency/entity qualifications; Minimum qualifications for all staff; No cost settlements; and Compliance with freedom of choice with no exemptions for DDSN and SCDMH.
Individuals with Intellectual and Related 1. Disabilities At Risk Children (includes: Severely & Seriously ED, EI, 2. Medically Complex, Foster Care & Juvenile Justice) Adults with Serious and Persistent Mental 3. Illness (re-name for Chronically Mentally Ill Adults) At-Risk Pregnant Women and Infants 4.
Individuals with Psychoactive Substance Disorder 5. Individuals at Risk for Genetic Disorders 6. Individuals with Head and Spinal Cord Injuries and 7. Related Disabilities 8. Individuals with Sensory Impairments 9. 10. Adults with Functional Impairments (FIA)
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Defined by SCDHHS as part of policy Requirement of all services billed to Medicaid
Developed SCDHHS and made available for review as part of policy changes SCDHHS will likely utilize its new QIO for this process.
All providers will be required to begin utilizing 15 minute unit of service.
An established system to coordinate services for Medicaid eligible individuals who may be covered under another program which offers components of case management or coordination similar to TCM (i.e., Managed Care, Child Welfare Services, as well as State waiver programs.); Demonstrate programmatic and administrative experience in providing comprehensive case management services and the ability and capability to differentiate Targeted Case Management services to be provided to the target group;
Staff with case management qualifications; and Establish referral systems, demonstrated linkages, and referral ability with essential social and health service agencies.
A minimum of three years providing comprehensive case management services to the target group; Administrative capacity to ensure quality services in accordance with state and federal requirements; Financial management capacity and system that provides documentation of services and costs in accordance with OMB A-87 principles; Capacity to document and maintain individual case records in accordance with state and federal requirements;
Demonstrated ability to meet state and federal requirements for documentation, billing and audits; Ability to evaluate the effectiveness, accessibility, and quality of TCM services on a community-wide basis;
Document that the provider is in good standing with local municipality or State of South Carolina as a recognized business or non-profit; and Must secure and store all records in-state or within 25 miles of the South Carolina border.
Possess a Bachelor’s degree in health or human services from an accredited college or university and have two years of supervisory experience and two years of case management experience; Be employed by the TCM Provider and not be on any State’s or the Office of the Inspector General’s Medicaid Exclusion List; and Be familiar with the resources for the service community.
Be employed by the TCM enrolled provider and not be on any State’s or the Office of the Inspector General’s Medicaid Exclusion List ;
Possess baccalaureate or graduate degree from an accredited college or university in a health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the individual being served and documentation of at least one year of experience working with the target population. The degree must be from an institution that is accredited by a nationally recognized educational accrediting body; Have the ability to access multi-disciplinary staff when needed;
Have documented experience, skills, or training in: ◦ Crisis Intervention; ◦ Effective Communication; and, ◦ Cultural diversity and competency. Possess knowledge of community resources; and, Possess a working knowledge of families and/or systems theory.
Office e Contact tact Rate $15.00/fifteen minute service unit Out-of of- Office e Non-Cong Congreg regate ate Contact act Rate $20.00/fifteen minute service unit
The following locations will be covered as an office contact to include the following congregate settings to include: • adult day care facility; • club house programs; • DDSN habilitation centers; • schools; or • Any setting in which the case manager sees two or more unrelated clients for the purpose of case management. Office contact will also include telephone contact .
Out-of-Office, Non- Congregate Contact
The TCM rate proposals described above are subject to CMS approval. The TCM market based rate was developed based on an analysis of annual compensation and fringe, travel, training, supplies, supervision and indirect cost of contracting state agencies and a Department proposed productivity factor.
It is anticipated that state agencies currently providing TCM services will be allowed a transition period of two years, SFY 2013 and SFY 2014, to fully implement the change from a cost based rate to a market based rate. During these two years, state agency specific cost based rates will be recognized as a component of the rate. For SFY 2013, the cost based component will comprise 75% of the TCM rate while the market based rate will make up 25%. The full implementation of the market based rate for TCM services will begin during SFY 2015.
Medicaid beneficiaries must be able to freely choose their case management provider from among those that have qualified to participate in Medicaid and are willing to provide the services. The State opted to not limit provider participation to specific persons or entities for individuals within the developmental disabilities or chronic mental illness target groups.
Next steps upon approval by CMS: Update policy Define medical necessity Develop and finalize Prior Authorization process Apply new provider enrollment process to all provider type. Phase in transition plan Finalize Freedom of Choice process
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